FETALSURE FETAL DOPPLER RENTAL HOME USE FORM Please complete the customer portion of the form. Have your health-care provider complete the provider portion. If your health-care provider needs information on any unit, they can visit the FetalSure home page: http://www.fetalsure.com WHEN COMPLETED, FAX THIS FORM TOLL FREE: 1-866-790-5168 CUSTOMER PORTION Patient Name:______________________________ Phone:  _______________ Address:  _______________________________________________________ City:_______________________________ State:  ______ Zip:  _____________ FETAL DOPPLER INFORMATION Model:Huntleigh Model FD1 or FD1+ Probe: 2 MHz OB Maker:Huntleigh Healthcare 40 Christopher Way Eatontown, NJ 07724-3227 Doppler Technology: Continuous Wave (CW) Unfocused. Display Rate (BPM):YES FetalSure Code: DD-01 LICENSED HEALTH-CARE PROVIDER PORTION Health-Care Provider Name:  ________________________________________ Address:  _______________________________________________________ City: _______________________________ State: ______Zip: _____________ Signature: ____________________________________ Date:______________   FetalSure ~ PO BOX 397 ~ Canfield ~ OH ~ 44406 Phone 1-800-598-3487 Fax: 1-866-790-5168